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��{{/VEL cb <br /> \Lr 2 V <br /> EN PER1MN'i�v1EV a HEALih <br /> Owner Statements of Designated Underground Storage Tank (US � for <br /> and Understanding of and Compliance with UST Requirements <br /> Facility Name: 7-11 17334 Facility ID#:17334 <br /> Facility Address: 4501'N.PERSHING AVE Reason for Submitting this Form(Check One) <br /> Stockton,CA 95207 ® Change of Designated Operator <br /> Facility Phone#: (209)951-6745 ❑ Update Certificate Expiration Date <br /> Designated UST Operator(s) for this Facility <br /> PRIMARY <br /> Designated Operator's Name: Michael Holkko Relation to UST Facility(Check One) <br /> Business Name(If different from above):Belshire Environmental Services,Inc. ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#: (949)460.5200 ❑ Service Technician ® Third-Party <br /> International Code Council Certification#: 6025470-UC Expiration Date: 2/212012 <br /> ALTERNATE 1 tion/ <br /> Designated Operator's Name: refer to the backup document Relation to UST Facility(Check One) <br /> Business Name(/f different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operators Phone#:refer to the backup document ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Dale:refer to the backup document <br /> ALTERNATE 2 (Optional) <br /> Designated Operator's Name:refer to the backup document Relation to UST Facility(Check One) <br /> Business Name(/f different from above):refer to the backup document ❑ Owner ❑ Operator ❑ Employee <br /> Designated Operator's Phone#:refer to the backup document ❑ Service Technician ® Third-Party <br /> International Code Council Certification#:refer to the backup document Expiration Date:refer to the backup document <br /> certify that, for the facility indicated at the top of this page, the individual(s) listed above will serve as <br /> Designated UST Operator(s). The individual(s)will conduct and document monthly facility inspections <br /> and annual facility employee training, in accordance with California Code of Regulations, title 23, section <br /> 2715(c)-(f). <br /> Furthermore,I understand and am in compliance with the requirements(statutes, <br /> regulations,and local ordinances) applicable to underground storage tanks. <br /> NAME OF TANK OWNER(Please Print): Stephen K. Boyd <br /> SIGNATURE OF TANK OWNER: -P-"� <br /> DATE: 9/13/2011 OWNER'S PHONE#: (714) 771-5484 <br /> NOTE: 1)SUBMIT THIS COMPLETED FORM TO THE LOCAL AGENCY(NOT THE STATE WATER <br /> RESOURCES CONTROL BOARD)BY JANUARY 1,2005. THE LOCAL AGENCY LIST IS AVAILABLE AT: <br /> www.waterboards.cactov/ustcontacts/cupa gays.html. <br /> 2) NOTIFY THE LOCAL AGENCY OF ANY CHANGES TO THIS INFORMATION WITHIN 30 DAYS OF THE <br /> /CHANGE. <br /> bftt(R November 2004 <br />